339,521 trained and dedicated polio workers work across Pakistan for polio eradication. The polio vaccine history of polio drops is critical for polio eradication.

Pakistan's Polio Eradication Roadmap

Introduction

<a href="https://merisehat.pk/disease/polio">Polio</a> is a crippling disease that mainly affects children below the age of 5 years and is caused by poliovirus. It is contagious, which means it can be transmitted from human to human.

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Polio is a global health concern. While the disease has been wiped off from most parts of the world through effective immunization campaigns, it remains endemic in Pakistan and Afghanistan. Nevertheless, it poses a serious threat to countries that have already eradicated the disease because a single person, who&rsquo;s infected with the poliovirus, can become a source of the global spread of the infection while traveling.&nbsp; 
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Understanding Pakistan's Fight Against Polio

Polio is a crippling disease that mainly affects children below the age of 5 years, and is caused by poliovirus. It is contagious, meaning it can be transmitted from human to human.&nbsp;

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The virus spreads through the fecal-oral route and very rarely through respiratory droplets when an infected person sneezes or coughs. Once the virus is inside the body, it reaches the intestines where it multiplies. Later, it invades the nervous system (spinal cord) and results in paralysis, a state of immobility of the body<a href="#accordion">[1][2]</a>. 
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Due to the disabling nature of the disease, polio eradication campaigns were launched worldwide to curb this highly infectious disease through immunization. There is no denying the fact that the eradication campaigns have been tremendously successful globally; the campaigns eradicated 99% of the polio infection.&nbsp;

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Although Pakistan is among the two polio-endemic countries, it has also worked significantly to eliminate polio from the region.&nbsp;

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This article will shed light on how Pakistan managed to pull off effective polio eradication campaigns throughout the years, despite a plethora of conspiracies, negative theories, and resistance by certain groups against the polio vaccine. Subsequently, there has been a massive reduction in polio cases in the region as compared to the pre-eradication era.&nbsp;

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Since Pakistan launched its Polio Eradication Program in 1994, the number of polio cases declined by 90%. There were roughly 20,000 polio cases each year in the early 1990s and, by 2018, this number had dropped to 8 cases, highlighting the significance of this initiative<a href="#accordion">[3]</a>.&nbsp;

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However, Pakistan needs to make it to 0 polio cases because as long as the virus keeps circulating in human reservoirs, the disease won&#39;t be eliminated and children will remain at risk of contracting the disabling infection. Therefore, it is the responsibility of every Pakistani to abide by the rules set by the polio eradication campaigns, and make the process easier for the vaccine administration to reach out to children in the door-to-door campaigns<a href="#accordion">[4]</a>.&nbsp; 
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Pakistan launched its Expanded Program of Immunization&nbsp;(EPI) in 1978. It involved immunization&nbsp;against vaccine-preventable diseases, including polio. Through EPI, only 2% of the population was vaccinated against polio in 1980, and by 1990 the polio vaccination coverage had reached 54% of the population<a href="#accordion">[5]</a>. 4 years later, in 1994, an independent polio eradication campaign was launched.&nbsp;&nbsp; 
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<h5>Pakistan&#39;s Polio Eradication Program - 1994</h5>

The first-ever polio eradication program was launched in Pakistan in 1994, and it was a collaborative effort between the Government of Pakistan (GoP) and the Global Polio Eradication Initiative (GPEI), partnered by WHO, UNICEF, BMGF, CDC, and Rotary International.&nbsp;

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Through this program, supplemental immunization activities (SIAs) were carried out during National Immunization Days (NIDs). Trivalent oral polio vaccine was administered during the SIAs and it proved to be effective against all the 3 strains of wild poliovirus. This was the first step towards creating a polio-free country. The CDC even predicted that Pakistan could be polio-free in the next 2-3 years following this program<a href="#accordion">[3]</a>. 
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<h5>Acute Flaccid Paralysis Surveillance - 1995&nbsp;</h5>

Acute flaccid paralysis (AFP) Surveillance was initiated in 1995. However, it became fully functional in 1998. Through this surveillance program, children under 15 years of age who had developed acute flaccid paralysis (AFP) were evaluated for polio infection.&nbsp;

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Evaluating polio cases through AFP surveillance is key to detecting polio cases in a given region as it signals the likelihood of the spread of the disease. The surest way to make the diagnosis of polio is to detect poliovirus in the stool sample of affected individuals. Upon detection of the virus, further investigations are carried out to identify the genetic type/strain of poliovirus causing the infection<a href="#accordion">[3][6]</a>.

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The AFP surveillance program started receiving undivided focus in 2000. As of now, Pakistan has a sensitive and highly effective AFP surveillance program at national, provincial, and district levels. Environmental surveillance has also been added to this program where sewage is checked to detect poliovirus.&nbsp;

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Pakistan is known to have the largest surveillance network in the world; there are 60 surveillance sites in 40 cities nationwide<a href="#accordion">[6]</a>. 
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<h5>Synchronization&nbsp;Of Pakistan And Afghanistan SIAs - 1998</h5>

Since Pakistan shares its border with Afghanistan and there is mass transit between the two all year round, there was a higher risk of the spread of polio in both the countries. Therefore, to ensure a comprehensive coverage of immunization between the two countries, this initiative was taken and vaccination activities in Pakistan and Afghanistan were synchronized<a href="#accordion">[3]</a>. 
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<h5>Stop Transmission Of Polio (STOP) Program - 1999</h5>

The STOP program was initiated in 1999 in Pakistan by the collaborative effort of WHO, CDC, and UNICEF. In this program, international healthcare professionals were deployed to Pakistan for 3-5 months to assist in the polio eradication activities, and to improve the quality of surveillance programs that were run in the country<a href="#accordion">[3]</a>. 
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<h5>House-To-House Vaccination Strategy - 1998-1999</h5>

A house-to-house vaccination strategy was implemented in 1998-1999 and expanded in 2000. This approach remains the cornerstone to the polio eradication strategy in Pakistan till date<a href="#accordion">[3]</a>. 
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<h5>March - 2001</h5>

Approximately 27 million children were vaccinated by March 2001 in hopes that the country would be polio-free by the end of the year<a href="#accordion">[5]</a>. 
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<h5>First &#39;Partnership for Polio Eradication&#39; Project - 2003-2006</h5>

GoP implemented the first &#39;Partnership for Polio Eradication&#39; project in 2003. The project was funded by the World Bank and the prime objective of this project was to facilitate Pakistan with the supply of 50% of the oral polio vaccine to be used during the period of 2003- 2005. The funds were transferred to UNICEF that was responsible for the procurement and distribution of the vaccines.&nbsp;

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During this period, 371 million oral polio vaccines were financed and in each round of immunization, 30 million children were vaccinated<a href="#accordion">[3]</a>.&nbsp; 
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<h5>First National EPI Policy - 2005</h5>

In 2005, the first National EPI Policy was adopted by the GoP with the aim of introducing new strategies for surveillance, and to tackle vaccine preventable diseases including polio<a href="#accordion">[3]</a>.&nbsp; 
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<h5>Monovalent Oral Polio Vaccine - 2005-2010</h5>

Monovalent oral polio vaccine was introduced in Pakistan against wild poliovirus strain type 1 in 2005, and against wild poliovirus type 3 in 2007. These monovalent oral vaccines were used until the introduction of bivalent oral polio vaccine in 2010<a href="#accordion">[3]</a>.&nbsp; 
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Second &#39;Partnership For Polio Eradication&#39; Project - 2006-2008

The second &#39;Partnership for Polio Eradication&#39; project was implemented in 2006. It was an extension of the first &#39;Partnership for Polio Eradication&#39; project that was held in 2003. The World Bank financed this project as well, and, likewise, UNICEF was responsible for the procurement and distribution of vaccines.&nbsp;

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From 2006-2008, 590 million oral polio vaccines were financed and 30 million children were vaccinated in each round of immunization. To optimize the polio campaigns and to improve quality, finger marking was introduced in 2008<a href="#accordion">[3]</a>. 
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<h5>Inter-Provincial Committee For Polio (IPCP) - 2009</h5>

The ICPC was chaired by the Federal Minister of Health in 2009, and the aim of the meeting was to address the challenges faced by the polio eradication campaigns at district and union council level<a href="#accordion">[3]</a>.&nbsp; 
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<h5>EPI Policy Revised To Introduce Lady Healthcare Workers (LHWs) - 2009</h5>

The EPI policy was revised in 2009 and it stressed upon the induction of Lady Healthcare Workers (LHWs) for the polio eradication campaigns. The LHWs who were trained in EPI were expected to deliver immunization, while those who weren&#39;t trained were given the task to assist during the vaccination campaigns<a href="#accordion">[3]</a>.&nbsp; 
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<h5>Third &#39;Partnership For Polio Eradication&#39; Project - 2009-2014</h5>

Similar to the previous two &#39;Partnerships for Polio Eradication&#39; project, this was also financed by WHO. UNICEF again was responsible for the supply of vaccine and its handling. During this project, 32 million children were immunized against polio in each round<a href="#accordion">[3]</a>.&nbsp; 
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<h5>National Emergency Action Plan (NEAP) - 2011-2020</h5>

The National Emergency Action Plan was launched in 2011, and an augmented plan was later launched in 2012. The NEAP focused on devising an annual strategic plan for the eradication of polio campaign. It was supported by the GPEI partners<a href="#accordion">[3]</a>.&nbsp; 
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<h5>PM&#39;s Polio Monitoring And Coordination Cell - 2011</h5>

The purpose of the PM&#39;s polio monitoring and coordination cell was to keep a check on the polio activities happening in the country as all the activities were reported to the Prime Minister<a href="#accordion">[3]</a>.&nbsp; 
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<h5>National Task Force On Polio Eradication - 2012</h5>

Eradication of polio was considered a national emergency by the President of Pakistan. Subsequently, the National Task Force on Polio Eradication was launched in 2012 and was chaired by the Prime Minister<a href="#accordion">[3]</a>.&nbsp; 
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<h5>National Vaccine Management Committee (NVMC) - 2012</h5>

The National Vaccine Committee (NVCM) was established under the Federal government and it included EPI, WHO, and UNICEF. This committee was responsible for vaccine management and vaccine storage. The formation of the committee was in response to UNICEF&#39;S recommendation regarding issues with vaccination storage and cold chain maintenance.&nbsp;&nbsp; 
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<h5>Revision Of Security Operations And Section 144 For The Criminal Procedure Invoked - 2012&nbsp;</h5>

After multiple attacks on the polio health workers, security operations were intensified. Additionally, a criminal code was invoked and through the implementation of this rule, it became a criminal offence if a parent refused to vaccinate his or her child against poliovirus, and any action could be taken against such parents<a href="#accordion">[3]</a>.

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During 2012, 58 cases of wild poliovirus were reported and in 2013, 98 cases of wild poliovirus were detected and they were all due to type 1 strain of the wild poliovirus. Out of the total 151 cases, 123 cases were reported in the Federally Administered Tribal Areas (FATA) due to resistance by militant groups<a href="#accordion">[7]</a>.&nbsp; 
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<h5>Polio Communication Approach Shifted As An Islamic Responsibility - 2013</h5>

In light of the controversies surrounding the oral polio vaccine, it was imperative to include Islamic scholars and members of Shariah council to educate the masses about the vaccine being completely permissible in the religion. It was done in 2013 with the unanimous agreement of the GoP and UNICEF. Maulana Sami ul Haq, an eminent Muslim leader, issued an Islamic ruling (fatwa) stressing on parents to get their children immunized against poliovirus<a href="#accordion">[3]</a>.&nbsp; 
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<h5>Emergency Operations Center (EOC) - 2014</h5>

The Emergency Operation Center was launched in 2014 at Federal and Provincial level. These centers were backed by the Polio Eradication Committee and they are responsible for managing the polio activities in their region<a href="#accordion">[3]</a>.&nbsp;

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In 2014, polio cases climbed to 306, the highest they have ever been since 2000<a href="#accordion">[5]</a>. However, due to constant efforts against the polio virus the number of cases dropped to 53 in 2015 and further declined to 20 cases in 2016<a href="#accordion">[8]</a>.&nbsp;&nbsp; 
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<h5>International Ulema Conference On Polio Eradication - 2014</h5>

The International Ulema Conference on Polio Eradication was held in 2014 and it was chaired by Islamic scholars from Saudi Arabia, Egypt, and Pakistan. In the conference, a fatwa was issued saying that it is permissible to get polio vaccine, and that it contains no harmful or forbidden (haram) ingredient<a href="#accordion">[3]</a>.&nbsp; 
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<h5>Revision Of The National EPI Policy And Induction Of Injectable Polio Vaccine (IPV) - 2015</h5>

In 2015, the National EPI policy was revised and it highlighted the commitment of the GoP to deliver safe and effective vaccinations against the vaccine-preventable diseases. Furthermore, injectable polio vaccine (IPV) was added to the schedule of the routine immunization<a href="#accordion">[3]</a>.&nbsp; 
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<h5>National Immunization&nbsp;Support Project - 2016</h5>

The National Immunization Support Project was launched in 2016 to get funds for the polio eradication campaigns, and to ensure equitable coverage against vaccine preventable diseases that include polio. This project aimed for a polio-free Pakistan by 2018<a href="#accordion">[3]</a>.&nbsp;

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A historic low of 8 cases was reported in 2017, after which the cases surged back. In 2018, 12 cases were reported; in 2019, the figures escalated to 147 before dropping to 84 in 2020<a href="#accordion">[9]</a>.&nbsp; 
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<h5>Polio Endgame Strategy - 2019-2023</h5>

The aim of the Endgame Strategy is to eradicate polio globally and most importantly in the polio endemic regions. This plan further aims to develop strong immunization centers to interrupt and break the chain of polio transmission.&nbsp;

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At provincial level, many polio eradication campaigns were held at Khyber Pakhtunkhwa and FATA region in 2014 and 2015, under the PTI government, to ensure that vaccine is dispensed in areas previously inaccessible due to security issues.&nbsp;

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On 27th January 2022, Pakistan achieved a historic milestone with no cases of polio being reported for a year. Unfortunately, an outbreak occurred soon afterwards in April 2022 and 11 cases were reported<a href="#accordion">[5]</a>. 
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Conclusion

Pakistan has fought bravely with the deadly poliovirus, and has been able to achieve 90% national coverage through its immunization&nbsp;efforts. Complete eradication of wild-polio type 2 and type 3 was achieved in 1997 and 2012 respectively, and only type 1 wild polio-virus remains endemic in the region. The immunization&nbsp;programs have been hindered by various political and environmental factors, but that has not stopped the GoP from making efforts against poliovirus. And health workers have worked diligently to make polio programs successful. Currently, Pakistan has 339,521 trained and hardworking polio workers that are the backbone of the polio eradication program<a href="#accordion">[2]</a>.

Key Points

<ul>
	<li>Pakistan and Afghanistan are the only two countries still struggling to eradicate wild-type 1 poliovirus.&nbsp;</li>
	<li>Pakistan initiated its polio eradication program in 1994 with the support of WHO, UNICEF, and other international organizations.&nbsp;</li>
	<li>Pakistan faced challenges during the polio eradication campaigns, but the mission remains unaffected and the campaign continues to regularly&nbsp;immunize&nbsp;children.&nbsp;</li>
	<li>Pakistan&#39;s polio cases have dropped by more than 90% as compared to the pre-eradication era.&nbsp;</li>
	<li>Multiple programs have been launched at national, provincial, and district level to ensure mass immunisation&nbsp;against the poliovirus, and to make the country polio-free.&nbsp;</li>
</ul>

[1] What is Polio? - CDC.

[2] "What Is Polio?." End Polio.

[3] Ataullahjan A, Ahsan H, Soofi S, Habib MA, Bhutta ZA. Eradicating polio in Pakistan: a systematic review of programs and policies. Expert Rev Vaccines. 2021;20(6):661-678. doi:10.1080/14760584.2021.1915139

[4] Polio | UNICEF Pakistan.

[5] Polio in Pakistan - Wikipedia.

[6] The Importance of Surveillance for Polio Eradication." 14 Oct. 2016.

[7] Alexander JP Jr, Zubair M, Khan M, Abid N, Durry E. Progress and peril: poliomyelitis eradication efforts in Pakistan, 1994-2013. J Infect Dis. 2014;210 Suppl 1(Suppl 1):S152-S161. doi:10.1093/infdis/jiu450

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